Hello, I'm Eric Strong from Strong Medicine and today in this ongoing video series on an approach to symptoms, I'll be discussing an approach to dysphasia. I'm going to start with a few terms. First is dysphasia itself, which refers to the symptom of difficulty swallowing. Dysphasia needs to be differentiated from odinophasia, which is painful swallowing. These two symptoms have overlapping list of ideologies and can coexist but they often don't. There's also a symptom called globus fingius which refers to a fullness or a sensation like there's a foreign body within the throat or esophagus but without an overt anatomic explanation like food impaction and typically without accompanying dysphasia. True dysphasia can be subdivided into oral fingial versus esophageal dysphasia. In oral feringial dysphasia, the patient experiences difficulty moving food and or liquid from the mouth into the esophagus. Whereas in esophageal dysphasia, the patient experiences difficulty moving food and or liquid from the esophagus into the stomach. The distinction is important because these two subtypes have completely different lists of ideologies and therefore different workups. Ideologies of oral feringial dysphasia can be subdivided into neurologic myopathic and other neurologic ideologies include stroke, any form of dementia, Parkinson's disease, ALS, multiple sclerosis or any lesion in the brain stem such as a malignancy. Myopathic ideologies include myioinia gravis and inflammatory myopathies such as polymyioitis. Ideologies in the other category include something called a zanker's diverticulum which is an outpouching of mucosa at the junction of the posterior fairings and upper esophagus just proximal to the upper esophageal sphincter. A variety of oral fingial tumors can lead to dysphasia. Dry mouth known more formally as zerostomia which can be a symptom of an autoimmune disease, a medication side effect or be idiopathic. Mucositis which is inflammation of the mucous membranes of the mouth which can occur during chemotherapy or radiation treatment and oral fingerial dysphasia can be a chronic complication of either radiation therapy or surgery within the oral cavity or ferinx. Moving to the ideologies of esophageal dysphasia, we can subdivide these into structural pathologies that are intrinsic to the esophagus, those exttrinsic to the esophagus and a separate category for motility disorders. Intrinsic causes include food impaction or foreign body. Both of these present acutely and are the only causes of dysphasia in this framework that are commonly medical emergencies. Reflux esophagitis and gird can cause dysphasia. Eocinophilic esophagitis is an immune mediated condition of incompletely understood pathogenesis characterized by eocinaphil predominant inflammation. Esophageal strictctures which can be the delayed result of ingestion of a costic substance. Esophageal rings and webs. Esophageal cancer is an important ideology. And last is infectious esophagitis such as that caused by HSV in Canada. Unlike many other ideologies in this framework, infectious esophagitis usually presents with significant odinophasia in addition to dysphasia. In the exttrinsic category are the pathologies which cause dysphasia by compressing the esophagus from the outside. This includes mediastinal masses such as tumors or massive lympadinopathy, aortic aneurysms, and something called a vascular ring, which is a congenital abnormality in which one or more great vessels completely surrounds either the trachea or esophagus or most commonly both. Depending on the severity of the compression, these can present within the first several weeks of life or be asymptomatic into adulthood. Within the last category for motility, the most well-known disorder here is echalasia. This is a condition of unknown pathogenesis in which there is a loss of normal paristalsis in the distal esophagus and the lower esophageal sphincter fails to relax after swallowing. Other motility disorders include diffuse esophageal spasms and something called nutcracker or jackhammer esophagus. These are similar diseases in which esophageal contractions are excessive. Chagus disease is an infectious disease caused by a parasite found in Central and South America. It causes a wide variety of complications including pathologies of the esophagus. At last, an autoimmune disease called systemic sclerosis, also known as scleroderma, can cause a loss of normal paristalsis. Notably, systemic sclerosis can also less commonly cause orphial dysphasia and reflux esophageitis. Overall the common causes of dysphasia are neurologic diseases of stroke, dementia and Parkinson's leading to oral fingial dysphasia and food impaction and reflux esophagitis causing esophageal dysphasia. How do we evaluate dysphasia? Starting with the history, the first task is to determine whether the patient is experiencing true dysphasia versus odinophasia versus both. Ask about the duration and pattern of dysphasia. Dysphasia that had a very abrupt onset is consistent with a stroke or food impaction. Is the dysphasia consistently present at every meal or only sometimes? Intermittent dysphasia is more often described with diffuse esophageal spasm, webs and rings and eocinophilic esophagitis. And does the dysphasia only occur when trying to swallow solid food or does it affect solids and liquids equally? Dysphasia that affects solids and liquids equally is suggestive of a neurologic or motility disorder while dysphasia that predominantly affects solids is suggestive of either intraluminal obstruction or external compression. Does a patient have associated symptoms? Heartburn suggests gird and reflux esophagitis while any cause of dysphasia if severe enough can cause weight loss. The more significant the weight loss has been, the more concerned about an underlying malignancy you should be. Vomiting and vertigo can be seen in brain stem lesions. Coughing, particularly coughing during meals, is suggestive of an oral feringial cause. Changes in speech including horarsseness can be due to either concurrent neurologic disease such as Parkinson's, lingial disease or mediastinal pathology. Hallettosis, which is the medical term for bad breath, is a classic symptom of a zanker's darticulum. And dry eyes can be a symptom of an autoimmune disease called Shogrin syndrome, which also causes dry mouth. In the past medical history, be sure to specifically ask about any neurologic or autoimmune disease, recurrent pneumonia and or aspiration, radiation therapy, or costic ingestion, and of course, any oral, neck, or thoracic surgery is very relevant. With a physical exam after vitals, the patient warrants an inspection of the oral cavity and a lymph node exam for any evidence of infection or malignancy. A focused abdominal exam, including palpation of the epigastric region, might rarely identify relevant pathology. Cardiac oscultation could reveal a murmur consistent with a vascular anomaly. But in general, the most important part of the physical exam for a patient presenting with dysphasia is a thorough neuroexam. Commonly ordered tests in the evaluation of dysphasia include something called a video fllororoscopic modified barium swallow test, more colloquially known as a video fllororoscopic swallow study. In this test, instead of a series of X-rays taken in one position, as would be the case with a conventional barium swallow study, a series of videos are taken, often with a patient in more than one position and sometimes with a patient drinking barerium contrast of different consistencies. Other tests include nasoparangoscopy in which the posterior fairings and larynx are directly visualized. This can help identify malignancy and may see evidence of a zanker's diverticulum. This test is often done as part of a fiber optic endoscopic evaluation of swallowing or fees in which the patient swallows while their posterior ferinx and larynx are being visualized with the endoscope. An esophagastroadoscopy or EGD is a key part of the evaluation of any patient whose dysphasia appears esophageal in origin. In this test, a flexible tube is inserted into the mouth through the upper esophageal sphincter of a sedated patient to directly visualize the interior of the esophagus and stomach. Biopsies can be taken of any visualized pathology and some pathologies such as a structure or esophageal ring can be potentially treated at the same time. Other tests occasionally ordered include a conventional barium swallow, esophageal monometry which can help identify motility disorders and a CT ch test which can identify medastinal masses. The first two of these six tests are primarily for evaluating oral fangial dysphasia while the last four are primarily for evaluating esophageal dysphasia. Now how do we apply all this information to create an approach to diagnosis? The first step in such an algorithm is to use history to distinguish probable oralopharrenial dysphasia from probable esophageal dysphasia. Oralopharrenial dysphasia is suggested by difficulty initiating a swallow meaning the dysphasia is immediate. If the patient reports drooling or spillage of food out of their mouth, a cough or choking sensation. if the patient requires repeated swallows to clear all the food out of their ferinx and if the patient has a history of pre-existing neurologic or myopathic pathology. On the other hand, features that suggest probable esophageal dysphasia include a delay of several seconds between the initiation of a swallow and the dysphasia sensation, the presence of odinophasia which is relatively uncommon in oral fingial ideologies with the exception of mucositis. A sensation of food getting stuck in the chest specifically suggests an esophageal cause when patients point to their sternum as a location from which the sensation appears to arise. And of course, a history of pre-existing esophageal pathology. History can provide further clues in the case of esophageal dysphasia. If there is dysphasia only from solid foods, it suggests a mechanical obstruction versus a similar degree of dysphasia from solids and liquids alike that suggests a motility disorder. From here, the algorithm diverges based on whether we suspect oral ferrenial or esophageal pathology. In suspected oral fangial dysphasia, if a specific diagnosis is strongly suspected, for example, a neurologic disease based on the neural exam, then continue with a focused workup as appropriate. Otherwise, if a structural ideology is felt to be most likely, including malignancy, the next step is typically nasoperangoscopy with or without endoscopic evaluation of swallowing. If a neuropathic or myopathic ideology is felt most likely, then a physoscopic modified barium swallow is typically done first. If whichever of those two that's done is either normal or non-diagnostic, it's usually followed by the other. If the nasoparangoscopy shows a visible abnormality, biopsy will usually provide the diagnosis. If the video fllororoscopic swallow study suggests pathology of the upper esophageal sphincter, this is usually further evaluated with monometry which directly measures the sphincter's pressure. If instead of suspected oral feringial dysphasia, you suspect esophageal dysphasia, the first decision point is the same. If there is a specific diagnosis strongly suggested, proceed with a focused workup as appropriate. For everyone else, the most common next step is an EGD. However, there are several alternatives that are occasionally considered for patients under the age of 50 who have no red flags for serious pathology. Sometimes they are first given a four-week trial of a proton pump inhibitor as empiric treatment for reflux esophagitis only followed by an EGD if the dysphasia is persistent. What are some red flags for serious esophageal pathology? weight loss, immuno compromise and the presence of either lympadinopathy or palpable epigastric mass on exam. Another alternative path is starting with a conventional barium swallow test in patients with known upper esophageal pathology such as a history of proximal strictcture with a thought being that having a better idea of the nature of the underlying pathology might reduce the risk of accidental esophageal perforation during the EGD. Among patients who receive an EGD, there are four possible outcomes. If there is an intrinsic abnormality seen of the esophagus, a biopsy is taken and a diagnosis is almost always made. Alternatively, if the EGD is normal and the patient has dysphasia just to solids, the next step is a barryium swallow which can identify intrinsic pathologies that are missed on EGD. On the other hand, if either the EGD or barerium swallow suggests exttrinsic compression, it should be followed by a CT of the chest to look for a mediainal mass and vascular abnormalities. And if the barium swallow or CT chest are done and are normal or if the EGD was normal in a patient with dysphasia to solids and liquids. This is all suggesting a motility disorder which usually requires esophageal monometry for diagnosis. If monometry is normal, one can consider a diagnostic category called functional dysphasia which basically means dysphasia in the absence of any demonstrable pathology versus a CT of the chest. if not already done as EGDs and barium swallows are not optimally sensitive for detecting the presence of exttrinsic compression. As you might have noticed, this algorithm is not quite as neat and streamlined as most others in this video series, suggesting that there is room for significant variability in the approach taken to an individual patient in practice. Finally, a complete negative workup for either oral fingial or esophageal dysphasia should prompt an evaluation of the other pathway as the patients medical history is not perfect for distinguishing these two categories in the first place. The key takeaway points for this video dysphasia refers to difficulty swallowing and needs to be distinguished from odinophasia which is painful swallowing. Dysphasia can be subdivided into two large categories. Oralopharangial dysphasia is difficulty moving food or liquid from the mouth into the esophagus. It is most commonly due to primary neurologic causes such as stroke or dementia. Esophageal dysphasia is difficulty moving food or liquid from the esophagus into the stomach most commonly due to primary diseases of the esophagus such as gird and food impaction. Last, although it is not a common ideology of this symptom, ruling out malignancy via nasoparangoscopy and/or EGD is a critical step in the evaluation of dysphasia. That's it for this video on an approach to dysphasia. Be sure to subscribe to Strong Medicine for more videos on how to approach symptoms as well as a broad variety of other medical topics.